Old surgical guidelines getting a fresh look

The ESRP approach includes skipping routine preoperative bowel preparation, using minimally invasive surgical techniques when possible, using goal-directed fluid therapy, minimizing the use of opioids in pain management, limiting the routine use of tubes and drains, and encouraging an early return to normal nutrition and physical activities.

“After implementing ESRPs, we have seen reductions in symptom burden, improvements in functional recovery, reductions in length of stay, and fewer complications,” said Vijaya Gottumukkala, M.D., a professor of Anesthesiology and Perioperative Medicine and an ESRP leader at MD Anderson.

Where appropriate, ESRPs replace traditional practices with newer, evidence-based practices. For example, patients have traditionally been told not to eat or drink anything after midnight the night before surgery. But with the new approach, patients can drink clear liquids until 2 hours before arriving for surgery. This simple change means patients are better hydrated on the day of surgery. Likewise, ESRPs allow most patients to resume eating regular food on the same day of their operation.

At MD Anderson, ESRPs increasingly focus on the use of short-acting intravenous anesthetics instead of volatile anesthetic agents. These practices help minimize patients’ postoperative confusion and allow them to emerge from anesthesia with less nausea, less vomiting, and better pain control, according to Gottumukkala.

Because each patient has unique needs, every patient may not receive each element of the ESRP approach. However, Thomas Aloia, M.D., an associate professor of Surgical Oncology and a co-leader of the ESRP for liver surgery, said that following the general principles and guidelines has resulted in noticeably better outcomes compared with the traditional approach.

Since the initiation of ESRPs, the median length of stay of patients who undergo open liver surgery has decreased by 2 days, and that of patients who undergo cystectomy has decreased by 3 days. In addition, total opioid consumption has decreased by up to 60% and opioid-related adverse events and gastrointestinal complications by up to 30%.

The ESRP approach has the potential to influence long-term outcomes in patients. “By continuing this program and this approach,” Gottumukkala said, “we aim to help patients return more quickly to their intended oncologic therapies, which ultimately may improve oncologic outcomes.”

This story originally appeared in the September 2015 issue of Oncolog. Read it in its entirety here.